STDs Micro

• Sexually Transmitted Diseases (STDs) are diseases in which sexual contact is epidemiologically significant, but it is not necessarily the only mechanisms of infection.

Urethritis

• Urethritis is the most common STD recognized in men.
• Types include:
  • Gonococcal urethritis
  • Non-gonococcal urethritis
  • Non-infectious urethritis

Gonococcal Urethritis

• Etiology is N.gonorrhoeae, which is a Gram-negative intracellular diplococcic.
• Incubation period is 2 to 7 days.
• Onset of symptoms is abrupt.
• Purulent urethral discharge occurs in 75% of cases.
• Dysuria is usually present.

Non-gonococcal Urethritis

• Etiology is C.trachomatis.
• Incubation period is 7 to 21 days.
• Other potential etiologies are U-urealyticum, T.vaginalis, Herpes simplex, Candida, etc.
• Purulent urethral discharge occurs in 15% of cases.
• Dysuria may be present.

Non-infectious Urethritis

• Systemic diseases:
  • Wegener's granulomatosis
  • Steven's Johnson Syndrome
• Chemical causes
  • Alcohol (dysuria)
  • Spermicides
• Other causes include renal stones, urethral trauma, and indwelling catheters.

Herpes Urethritis

• Symptoms include severe dysuria, mucoid urethral discharge, and regional lymphadenopathy.
• Patient will experience constitutional symptoms.
• Genital lesions not always present.

Gonococcal Urethritis - Diagnosis and Treatment

• Diagnosis:

  • Use Gram stain of urethral exudate
  • Culture on Thayer-Martin
  • The organism is fastidious requiring CO2 and a rich environment

• Treatment:

  • Ceftriaxone 125mg IM
  • Ciprofloxacin 500mg PO plus Doxycycline 100mg P.O. bid x 7 days

Non-gonococcal Urethritis - Diagnosis and Treatment

• Diagnosis:

  • C. trachomatis: NAAT'S or DNA probe
  • U. urealyticum: culture
  • T. vaginalis: culture, wet mount to see motile protozoa

• Treatment:

  • Doxycycline 100mg P.O. bid x 7 days or Azithromycin 1 gm P.O.
  • For T. vaginalis, use metronidazole 2gms P.O.

Cervicitis

• Cervicitis is the the most common STD in women.
• Potential pathogens include:
  • N. gonorrohoeae
  • C. trachomatis
  • H. simplex virus
  • Human papilloma virus

Gonococcal Cervicitis

• Symptoms:
  • Causes purulent cervical discharge and cervical edema.
  • Dysmenorrhea, dyspareunia, and dysuria
  • 50% have urethritis associated

C. trachomatis

• Causes mucopurulent cervicitis.
• Symptoms:
  • Abdominal pain
  • Spotting with intercourse
  • Only 30% show vaginal discharge

Herpes Simplex

• Mucoid discharge lower abdominal pain
• Cervix is friable, ulcers and necrosis.
• External lesions are clinically absent.

Cervicitis - Diagnosis and Treatment

• Diagnosis:
  • Gram stain of endocervical mucus > 10 WBC's
  • Cervical biopsy – HSV
  • Colposcopy
• In terms of treatment N. gonorrohoeae and C. trachomatis are targeted.

Cervicitis - Complications

• Endometritis, salpingitis PID, ectopic pregnancies, infertility can occur.
• During pregnancy, PROM, premature birth, low birth weight, spontaneous abortion, intrauterine death can occur.
• Promotion to cervical neoplasia and perinatal infections during delivery are complications.

Vulvovaginitis

• Includes:
  • Vulvovaginal candidiasis
  • Bacterial vaginosis
  • Trichomoniasis

Vulvovaginal Candidiasis

• 75% of women experience at least 1 episode
• Candidiasis can be present in healthy women.
• Leads to pruritus, dyspareunia, and white discharge.
• Is associated with antibiotics, oral contraceptives, corticosteroids, pregnancy, and DM.
• C. albicans is the etiology 90% of the time.
• Normal vaginal fluid pH is typical.

Bacterial Vaginosis

• Is the most common cause of infectious vaginitis.
• May be asymptomatic.
• Moderate gray discharge is present.
• pH vaginal fluid >4.5.
• Amine test (+) shows “fishy odor” on whiff test.
• Gram stain shows “clue cells“.

Trichomona Vaginitis

• Copious amount green-yellow discharge.
• Dyspareunia and vaginal fluid pH of 5-6 occur.
• Amine test (+) whiff test.
• Identified 40% of male partners as carriers.
• During menses, pH increases.

Infectious Vaginitis - Treatment

• Vulvovaginal candidiasis:
  • Treat with topical antifugal-clotrimazole or miconazole
  • Fluconazole 150mg can also be used
• Bacterial vaginosis:
  • Metronidazole 500mg P.O. bid x 7 days
  • Topical metronidazole can also be used.
• Trichomoniasis:
  • Metronidazole 2 gms. P.O.

Human Papilloma Virus (HPV)

• This is the most common STD.
• Symptoms may develop after years.
• It may disappear in two years in 9/10 cases.
• HPV may cause cancer of the vulva, vagina, penis, anus, and oropharynx.

Human Papilloma Virus (HPV) - Prevention

• Vaccination in boys and girls between 9-26 years protects against HPV.
• Screening, condoms, and monogamous relationships are also preventive.
• Associated cervical lesions may put a patient at increased risk of carcinoma of the cervix.

Genital Ulcers

• Types include:
  • Syphilis
  • Chancroid
  • Genital herpes
  • Lymphogranuloma venereum
  • Donovanosis

Syphilis - T. Pallidum (spirochete)

• Incubation is 21 days up to 90 days.
• Lesions - single or multiple, sharply demarcated, smooth base or crusty, firm, painless.
• Unilateral or bilateral lymph nodes occurs.
• Dx: darkfield microscopy, VDRL, FTA
• Rx: Penicilline/Doxycycline or Ceftriaxone.
• Can lead to Jarish-Herxheimer reaction.

Chancroid – H. Ducrey (GNB)

• Incubation 2-7 days up to 35 days.
• Lesions may be multiple, erythematous borders, undermined, yellow-gray rough base, painful.
• Unilateral lymph nodes, may be fluctuant.
• Dx: culture, supplement agar, CO2, and Vancomycin.
• Rx: Ceftriaxone X 1 or Azithromycin x 1 or Ciprofloxacin x 3 days.

Genital Herpes (HSV)

• Incubation is 2 – 7 days.
• Lesions may coalesce, erythematous borders, red smooth base painful.
• Bilateral firm tender nodes occur.
• Dx: Tzanck smear, viral culture
• Rx: Acyclovir x 10 days, Valacyclovir, Famciclovir

Lymphogranuloma Venereum (LGV) - Chlamydia Trachomatis

• Incubation 10-14 days up to 3 weeks.
• Lesions usually single, variable borders, variable base, non indurated, and may be tender.
• Usually unilateral firm tender nodes, may fluctuate, suppurate, fistulas, and sinuses.
• Groove sign-pathognomonic is present in 30% of patients.
• Dx: culture < 30%
• Rx: Doxycycline x 21 days or Tetracycline x 21 days

Granuloma Inguinale - Donovanosis - Klebsiella Granulomatis

• Incubation 3-180 days.
• Lesion is small painless papule or nodule, elevated borders, red, rough friable base, beefy granulations, may be hypertrophic, verrucoaus, and necrotic.
• Inguinal swelling occurs with pseudoadenopathy.
• Dx: Giemsa, Wright's stains – “Donovan bodies".
• Rx: Trimetroprim-sulfamethoxiazole x 3 weeks, or Ciprofloxacin x 3 weeks.

Herpes Infection during Pregnancy

• Abortion and premature labor can occur.
• Skin lesions and chorioretinitis can lead to microcephaly and uterine growth retardation.

Neonatal Infections

• They can be localized to disseminated.
• Have a higher incidence of premature delivery.

Syphilis

• Syphilis is a subacute to chronic infectious disease by Treponema pallidum.
• It is usually acquired by sexual contact.

The Pathogenesis of Syphilis

• T. pallidum penetrates through normal mucosal membranes and minor abrasions of epithelial surfaces.
• The first lesion appears at the site of primary inoculation.
• Only one treponema may establish infection.
• Patient is not known to produce toxins.
• Primary pathologic lesion-focal endarteritis where vessel lumen is obliterated.

Primary Syphilis

• Typical legion is the chancre-painless indurated ulcer, regional adenopathy.
• It starts as a papule, then a superficial erosion resulting in the typical ulcer.
• Borders are raised, firm and indurated.
• Heals in several weeks.
• 90% occurs in the genital region.
• Rectal chancres may mimic rectal fissures.
• It may be seen in the pharynx, tongue, lips, fingers, and nipples.
• May be confused with genital herpes.

Secondary Syphilis

• Symptoms arise 4 to 8 weeks after chancre.
• Patient will develop malaise, fever, headache sore throat, lymphadenopathies.
• Cutaneous eruption-widespread and symmetric in distribution, and is non-pruritic.
• Often symptoms are pink, coppery and red.
• Patient will develop indurated having a superficial scaly papulosquamous lesion.
• Condyloma lata-large pale flat papules, may coalesce, verrucous lesions and are highly infectious.
• May be seen in axilla, perineum, perianal.
• Mucous patch, raised oval area covered with grayish-white membrane may be seen in genitalia, mouth, tongue, and is highly infectious.

Late Syphilis

• Late benign syphilis (gummatous), cardiovascular and neurosyphilis may occur.

Congenital Syphilis

• Results from transplacental, hematogenous spread.
• VDRL should be obtained in all expectant mothers.
• Spirochetes can be found in abortus.
• Treatment of mother prior to 16th week will prevent neonatal, illness.
• Resembles secondary syphilis.
• Rhinitis, hepatosplenomegaly, hemolytic anemia, jaundice, thrombocytopenia symptoms will occur.